ATI Learning System 3.0 - Fundamentals 2

a nurse is teaching a client who is recovering from gallbladder surgery how to use an incentive spirometer. Which of the following information should the nurse include in the teaching?

Hold breath for 5 seconds after goal volume is reached. rationale: the nurse should instruct the client to hold her breath for 3 to 5 secs after reaching maximal inspiratory volume. This decreases the collapse of alveoli, which helps to prevent the risk of atelectasis and pneumonia

A nurse is caring for a toddler at a well-child visit when the mother calls to the nurse, "Help! My baby is choking on his food." Which of the following findings indicates the toddler has an airway obstruction?

Inability of the toddler to cry or speak rationale: When the client has no sound passing through the vocal cords, the nurse should identify a complete airway obstruction is evident. The nurse should use the Heimlich maneuver to dislodge whatever is obstructing the trachea.

a nurse is preparing to remove an NG tube for a client who had a partial colectomy. Which of the following actions should the nurse take?

Pinch the NG tube while removing the tube rationale: the nurse should pinch the NG tube while removing the tube to decrease the risk of aspiration of any gastric conents

A nurse is caring for a client who has a history of dysrhythmias. Upon entering the room, the nurse discovers the client is unresponsive to verbal and painful stimuli, has no respirations, and is pulseless. Which of the following actions should the nurse take first?

Start chest compressions rationale: the nurse should apply the safety and risk reduction priority-setting framework when caring for the client. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the hight priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. The nurse should perform cardiopulmonary resuscitation(CPR), which starts with chest compression, then opening the airway, and breathing for adults and pediatric clients bc evidence indicates there is a great survival rate when chest compressions are started before a breath is initiated.

a nurse is planning care for a client who has a prescription for collection of a sputum specimen for culture and sensitivity. Which of the following actions should the nurse take when obtaining the specimen?

collect the specimen upon arising in the morning rationale: The nurse should plan to collect the sputum specimen when the client arises in the morning bc the client is able to more easily cough up the secretions that have accumulated during the night. Generally, the deepest specimens are obtained in the early morning, and it is preferable to collect the specimen before breakfast. The nurse should instruct the client to rinse the mouth, take a deep breath, and cough prior to expectorating into the sterile container.